Provider Demographics
NPI:1417040767
Name:PEZZULICH, LISA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:PEZZULICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BENMONT AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1873
Mailing Address - Country:US
Mailing Address - Phone:802-442-3520
Mailing Address - Fax:802-447-3392
Practice Address - Street 1:160 BENMONT AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1873
Practice Address - Country:US
Practice Address - Phone:802-442-3520
Practice Address - Fax:802-447-3392
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000729103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1922Medicaid
VTPEVN1922Medicare ID - Type Unspecified